Eden Alternative grows Green House initiative

Nearly two decades ago, William Thomas M.D., then a University of Rochester resident, was working at a part-time job at a nursing home where one day he walked into a resident's room.

Thomas, who frequently repeats the story of the encounter that followed as sparking a life-changing epiphany, describes himself as announcing his presence to a bed-ridden elderly female resident with "incredible blue eyes" by shouting, "Hi, I'm Dr. Bill; what can I do for you today?" The woman had a rash on her arm and he applied a cream, Thomas says. He then asked if there was anything else he could do.

The woman grabbed his arm, pulled him to her and said: "Doctor, I'm so lonely."

That flummoxed him, Thomas admits. He did not know what to say, so he patted the woman's hand and left the room. But he could not stop thinking about the incident.

In an effort to discover a way to address the lonely woman's plaint, Thomas set out to consciously observe conditions at the home. He sat and watched in the home's solarium, in dining areas and in hallways and finally reached a conclusion: Boredom, loneliness and feelings of helplessness were pervasive among residents and such feelings were sapping their vitality as surely as any physical ailments. Thomas decided to switch from family medicine to geriatrics.

In 1992, Thomas and his wife, Judith-who for some years have lived on a farm near Ithaca-started a non-profit. They called it the Eden Alternative. The name is a nod to a formulation Thomas arrived at after his youthful nursing home epiphany: that people were designed to live not in sterile facilities but in a garden. The organization's ambitious aim is to promote a paradigm shift in skilled-nursing facility operation or, in the words of its mission statement, "to improve the well-being of elders and those who care for them by transforming the communities in which they live and work."

In the factory model of nursing home management, Thomas says, staff's day-to-day responsibilities consist largely of making sure their charges take their medications, eat their meals, do not wander too much and do not fall. Nurses, aides and doctors primarily are focused on ensuring that procedures are followed and that the home runs smoothly.

In an Eden Alternative home, staffers strive to be more like facilitators helping residents to make their own choices. Amenities such as pets and gardens are encouraged. In Thomas' view, the key to achieving change does not lie in changing procedures or methods but in changing attitudes.

"A change of heart is what it's all about," Thomas says. "The current (long-term care) system is obsessed with illness. When most institutions think about their residents, they think in terms of illness. (The Eden Alternative) is not being concerned about what people can't do but about what they can do. It's a simple concept, really-that it's better to live in a garden than in a hospital."

The Eden Alternative has made inroads. Some 200 U.S. nursing homes as well as facilities in Canada, Europe, New Zealand and Japan have signed on with Eden Alternative as registrants, and the organization has developed a nationwide network of mentors and teachers to spread its ideas.

In 2002, Thomas, who is now 48, and his wife named a board of directors, which hired an executive director and staff to run the operation. He remains on the Eden Alternative board but spends much of his time traveling to promote his ideas at conferences and events around the country as an AARP visiting scholar. He also has authored several books and this year started teaching a course at the Erickson School on Aging, Management and Policy, which is part of the University of Maryland, Baltimore County.

Precisely measuring the Eden Alternative's impact on nursing home operation is difficult. The number of facilities currently registered with the organization represents a tiny fraction of all nursing homes and the group's registry is not an accreditation, so there is no systematic accounting of how close registered facilities come to achieving the Eden Alternative ideal.

A 2002 study published in the Journals of Gerontology compared outcomes at two nursing homes in the same system over the course of a year. One implemented Eden Alternative methods; the other did not. The authors found "no beneficial effects in terms of cognition, functional status, survival, infection rate, or cost of care after one year" at the home run on Eden Alternative principles. Still, they noted that at the Eden site "the change was positive for many staff as well as residents, suggesting that it may take longer than a year to demonstrate improvements."

A 2003 study of family satisfaction with loved ones' care under Eden Alternative methods published in the Journal of American Medicine found significant improvement over a two-year period.

The Eden Alternative, meanwhile, has continued to evolve. A recent initiative called Green House aims to see nursing homes converted from large institutional facilities to smaller, home-like "communities" of no more than 10 residents each. The initiative has won high-level support, including backing from the Robert Wood Johnson Foundation, which is supplying a $15 million grant to help promote the

Green House movement.

The first Eden Alternative Green House went up in 2004 in Tupelo, Miss. Some 40 more now have been built and dozens are in planning stages.

One of the most ambitious Green House projects is in the works in Rochester, where St. John's Home hopes eventually to put up eight to 10 Green Houses on two- to three-acre sites scattered across Monroe County. Construction of the first two is targeted to begin next summer with 20 residents transferred from St. John's Home by the end of next year.

A later phase of the project is planned that would be even more ambitious than the 10-Green House plan. It would involve a complete renovation of St. John's Home's facility on Highland Avenue that would turn the 450-bed nursing home into 40 or so discrete Green House modules.

St. John's Home is working on a master plan for the Green House project, CEO Charles Runyon says. He expects to submit the plan along with a certificate-of-need application to the state Department of Health for approval to build the first two Monroe County Green Houses in November. St. John's Home has identified several potential sites for the construction but is not yet in a position to say where they are, he says.

Thomas, who has been consulting with St. John's Home staff and the state Health Department on the project, calls the plan to retrofit the St. John's facility "something new and different" and says he is encouraged by state officials' interest in the project.

"The New York Department of Health has been cooperative," Thomas says. "The state has really encouraged St. John's Home to be creative. There's 30 years of attitude and regulation that need to be overcome, but I think the state is now starting to see the need for creativity."

"Discussions with St. John's have been very positive," says department spokesman Jeffrey Hammond, who adds that officials look forward "to reviewing their (Green House certificate of need)."

Barber has been a driving force behind St. John's Home's Eden Alternative and Green House push. She first heard of Eden Alternative at a Washington, D.C., conference some six years ago and immediately became a fierce advocate.

"She came back on fire," Runyon says. "At first I was a little skeptical."

Any qualms he had at the time have faded now. Runyon is fully on board with the Eden Alternative and Green House pushes.

"You can build a smaller nursing home, but it's still a nursing home," Runyon observes. "What we really want to do is revolutionize long-term care."

Among changes wrought so far, he says, are efforts to encourage staffers to police themselves and think creatively about problems and above all to think of residents first. If a worker in a given unit is chronically late, fellow employees are supposed to work with that person on the problem. And all staffers are supposed to be ready to dig in and do whatever is needed to make residents feel at home. Administrators should not be shy about making a bed or wheeling a resident into a dining area.

Some five years into the Eden Alternative push, Runyon says, "we're probably about halfway there. We've reached a tipping point where more people get it than don't, but not everybody is going to get it. There's going to be milk spilt. Some people are going to leave; some people are going to stay. But it took five or six years to get where we are, and I expect it to go faster now."

Barber and Runyon see evidence that Eden Alternative methods are working in St. John's Home's relatively low employee turnover rate of less than 10 percent.

The low staff turnover is encouraging, Runyon says, because like virtually all nursing homes, St. John's Home faces ongoing money challenges. Seventy percent of its residents are on Medicaid, which pays less than it costs to house them.

Staying out of the red takes a juggling act. Medicaid underfunding can be partially offset by higher private-pay rates, private fundraising and other means, including low pay scales. This affects not only lower-rung employees such as aides and cleaning staff but also professional staff. Nurses can pull in far better money at hospitals, which avidly compete for their services.

Given the financial constraints of long-term care, paying for the extensive buildout St. John's Home envisions to complete its Green House master plan poses risks, Runyon concedes.

"Funding could be a barrier," Thomas concurs, but he also suggests that one might consider the alternative. "Virtually no institutions are more dreaded than nursing homes. We spend $80 billion a year now on a system nobody likes." n